Icd 10 Code for Family History of Dm2

March 08, 2022 Post a Comment

ICD-10: Major Differences for Five Mutual Diagnoses

Test your knowledge of ICD-10 coding and documentation requirements for 5 diagnoses you're likely to encounter in family medicine.

Fam Pract Manag. 2015 Sep-Oct;22(five):fifteen-21.

Author disclosure: no relevant financial affiliations disclosed.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

Commodity Sections

Introduction
Beginning, why should y'all care?
What to report
Five common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Across the top v
Don't panic
References

The fourth dimension has come. Are you lot ready for the Oct. 1 transition to ICD-10 diagnosis coding? If you are not sure, yous are not alone. Many elements of this transition have depended on your software vendors, clearinghouses, payers, and staff, but there is one affair you can control: your documentation of the information necessary to support the diagnosis codes yous choose to bill. Your documentation probably does not need a major overhaul, merely you volition need to exist more specific and detailed in sure areas. In this article, we will expect at the documentation elements required to support ICD-10 code option, focusing on v common weather condition in family medicine. Quizzes will examination your knowledge throughout the commodity.

Offset, why should y'all intendance?

Abstract
Starting time, why should y'all care?
What to study
5 common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number two: well-kid examinations
And the number ane diagnosis is…
Beyond the top v
Don't panic
References

The increased specificity required in your documentation and coding nether ICD-x may seem unnecessarily burdensome. However, diagnosis coding has a wider impact than you might immediately recognize.

Question: In which of the post-obit means does diagnosis coding affect md practices and patient care?

Diagnosis codes support the medical necessity of services provided.
Diagnosis codes back up claims payment.
Diagnosis data is increasingly used to evaluate cost and quality of care.
Diagnosis data is used to influence public wellness policy.
All of the in a higher place.

Reply: The diagnosis codes reported on doctor claims must be supported not just to facilitate payment but as well because they go the information upon which decisions beyond claims payment are made. The correct answer to the above question, then, is East, all of the to a higher place.

Documentation that supports specific diagnosis coding also may alleviate burdensome medical record requests from third parties. Take for instance the following statement a physician forwarded to me from a claims administrator regarding medical record requests to support risk adjustment: "ICD-nine-CM (or its successor ICD-10-CM) diagnosis codes make up one's mind a patient's run a risk score. The more than diagnosis detail submitted with claims and encounters, the less likelihood that [insurer proper noun redacted] will demand to request and inspect medical records." In other words, if your documentation supports the level of service coded and the selected diagnosis codes specifically place the nature of your patient's condition, you are less likely to receive a request for your medical record. If a request is fabricated, your documentation will back up both the service provided and why it was provided.

DOCUMENTATION ELEMENTS FOR Common DIAGNOSES

This article contains 7 tables outlining the documentation elements for mutual diagnoses. All seven tables are bachelor for download as a unmarried resource.

Download in PDF format

What to report

Abstract
Start, why should you care?
What to report
Five common diagnoses
Number 5: asthma
Number four: otitis media
Number three: diabetes
Number two: well-kid examinations
And the number one diagnosis is…
Across the top five
Don't panic
References

Earlier we review common diagnoses, it is important to know when codes should and should not be reported for a condition.

Question: According to the official guidelines for ICD-10, which of the following weather condition should be reported?

All conditions listed in the problem list.
Only conditions with confirmed and differential diagnoses.
All conditions that require or touch patient intendance or treatment at the fourth dimension of the come across.
Only the condition related to the chief complaint.
Conditions that are probable.

Answer: The ICD-10 guidelines (like ICD-nine) specify that physicians should not written report the following:

Conditions documented every bit probable, likely, or to be ruled-out (rules differ for facilities),
Codes for symptoms that are integral to an established diagnosis,
Atmospheric condition that are no longer present,
Conditions that did non impact management or treatment at the electric current meet.

Therefore, the answer to the question is C. All weather that require or impact patient care or handling at the fourth dimension of the encounter should exist reported. Physicians should listing beginning the condition that is chiefly responsible for the services provided and lawmaking what is known at the time of the see.

This didactics to code what is known at the fourth dimension of the encounter is important. Based on this guideline, physicians should study unspecified codes such as J12.9, unspecified viral pneumonia, when the data known at the fourth dimension of the encounter does not support a more than specific diagnosis. The guidelines state, "It would exist inappropriate to select a specific code that is not supported by the medical tape documentation or comport medically unnecessary diagnostic testing in lodge to determine a more specific code."

Other important documentation guidelines include the following:

List first a disease and then associated manifestations,
Link sequelae (late or remainder weather) to the history of an injury or by medical condition,
Report personal or family unit history codes when the history affects care or influences treatment.

Five mutual diagnoses

Abstract
First, why should you care?
What to written report
V common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Beyond the elevation five
Don't panic
References

With so many diagnoses in master intendance, it makes sense to focus your ICD-10 education efforts on those that are common in your specialty. The National Center for Health Statistics provides this data.1

Question: Which status is the top reason for office or other outpatient visits to family physicians?

Diabetes.
Hypertension.
Otitis media.
Asthma.
Well-kid examinations.

Reply: All of the to a higher place conditions are near the meridian of the list for family medicine, simply for the number ane diagnosis, you'll accept to read on. Let's take a look at five commonly reported diagnoses and their documentation requirements nether ICD-ten.

Number five: asthma

Abstruse
First, why should you care?
What to written report
5 mutual diagnoses
Number v: asthma
Number four: otitis media
Number three: diabetes
Number ii: well-child examinations
And the number ane diagnosis is…
Beyond the top 5
Don't panic
References

Asthma nomenclature in ICD-ten mirrors the guidelines from the National Asthma Educational activity and Prevention Program, which differs from ICD-9.2

Question: Which of the following is non an pick for the classification of asthma in ICD-10?

Intrinsic.
Balmy intermittent.
Mild persistent.
Moderate persistent.
Severe persistent.

Answer: All of the in a higher place classifications are options in ICD-x except A, intrinsic. That was the old terminology used in ICD-9.

In addition to documenting the asthma classification, physicians should document the status of the condition at each encounter. "Tabular array one: Documentation elements for asthma" includes the codes for each asthma classification by status.

Table one:

Documentation elements for asthma

Asthma classification	Condition	Code
Mild intermittent	Uncomplicated	J45.20
	With exacerbation	J45.21
	Status asthmaticus	J45.22
Mild persistent	Uncomplicated	J45.30
	With exacerbation	J45.31
	Condition asthmaticus	J45.32
Moderate persistent	Elementary	J45.twoscore
	With exacerbation	J45.41
	Status asthmaticus	J45.42
Severe persistent	Unproblematic	J45.l
	With exacerbation	J45.51
	Condition asthmaticus	J45.52

If y'all were to certificate asthma without specifying the nomenclature or status, that would be reported with code J45.909, unspecified and uncomplicated asthma. All the same, consider the implications of reporting J45.909 for a patient who is non compliant with control medications, is seen for an astute exacerbation, and requires a revised care programme. This code not only fails to identify the nature of the patient presentation but likewise fails to convey the cess of the asthma status and the complicating factor of noncompliance. Documenting a scrap more than detail – moderate persistent asthma with exacerbation, J45.41 – improve conveys the nature of the meet. Code Z91.14 could exist added to specify the patient's poor compliance with control medication and explain the patient management complications.

Number four: otitis media

Abstract
First, why should you care?
What to report
V common diagnoses
Number v: asthma
Number iv: otitis media
Number iii: diabetes
Number two: well-child examinations
And the number ane diagnosis is…
Across the top five
Don't panic
References

Both ICD-9 and ICD-x provide codes to specifically place otitis media as acute or chronic and every bit serous, allergic, or suppurative. Despite the availability of more specific codes, ICD-9 lawmaking 382.9 (unspecified otitis media) was frequently reported. Utilize of an unspecified code is appropriate when no farther information is known at the time of the encounter; yet, more specific reporting is appropriate when further information is known, and it typically better supports the level of service rendered.

Question: Specific reporting of otitis media includes which of the following documentation elements?

Blazon (east.g., serous).
Laterality (e.thousand., left).
Occurrence (e.g., chronic).
Tympanic membrane status (eastward.g., ruptured).
All of the above.

Answer: Each of the to a higher place documentation elements is important to fully identify the nature of the otitis media – answer East. An cess of bilateral acute otitis media without indication of type (serous, suppurative, or in a disease classified elsewhere) would support lawmaking H66.93 (otitis media, unspecified, bilateral). But better documentation, such equally acute recurrent bilateral suppurative otitis media without spontaneous rupture of the ear drum (H66.006), may help to identify the need for college levels of medical decision-making or additional services. (See "Tabular array ii: Documentation elements for otitis media.")

Table 2:

Documentation elements for otitis media

Otitis media type	Code family unit	Occurrence	Laterality	Tympanic membrane status
Serous/nonsuppurative	H65.--	Acute/subacute Acute recurrent Chronic	Correct Left Bilateral	Ruptured Not ruptured
Suppurative/purulent	H66.--
In a illness classified elsewhere (influenza, measles, viral illness), follow index pedagogy (combination code or H67)	H67.-- or combination code

Number three: diabetes

Abstruse
First, why should you care?
What to study
V common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number ii: well-kid examinations
And the number one diagnosis is…
Beyond the top five
Don't panic
References

Key documentation elements for diabetes are the type of diabetes, manifestations of the disease, and utilise of insulin (not necessary for type one diabetes). "Table 3: Documentation elements for diabetes" illustrates the requirements.

Table 3:

Documentation elements for diabetes

Diabetes blazon	Code family	Manifestation	Insulin use
Blazon one	E10.--	Consider whether the condition is controlled; uncontrolled is a manifestation (hyperglycemia) Make a connectedness (east.g., diabetic ulcer vs. diabetes, ulcer) Describe the manifestation (east.g., site and severity of ulcer)	n/a
Type 2*	E11.--		Z79.4 Long-term (current) insulin use
Due to underlying status	E08.--
Drug or chemical induced	E09.--

Question: Which of the post-obit documentation elements would be required to accurately code an meet with a patient who has diabetes, loss of protective awareness, a pes ulcer, and an elevated A1C result?

Type of diabetes.
Location of the ulcer.
Related weather condition (manifestations).
Condition status/characteristics (e.g., uncontrolled).
All of the above.

Reply: If y'all chose Due east, all of the above, y'all are right. Because this patient has manifestations, boosted codes should be reported to describe the documented manifestations. Conditions such as type-2 diabetic neuropathy may be captured in a single combination code (eastward.1000., E11.40 for diabetes type 2 with neuropathy). However, fifty-fifty combination codes cannot adequately depict some manifestations. A diabetic foot ulcer may be separately reported based on three documentation elements: site, laterality, and severity. (Run across "Table four: Documentation elements for foot ulcer.") Codes describing nonpressure ulcers (categories L97.1-L97.9 and L98.41-L98.49) may exist reported in addition to codes describing type ii diabetes with foot or other skin ulcer (categories E11.621-E11.622).

Tabular array four:

Documentation elements for nonpressure chronic human foot ulcer

Human foot ulcer site	Code family	Laterality	Severity
Heel and midfoot	L97.4--	Correct Left	Express to breakup of pare Fat layer exposed Necrosis of muscle Necrosis of os
Other part of foot including toe	L97.5--	Correct Left

(For more information on documenting diabetes in ICD-x, see "Getting Set for ICD-10: How It Volition Affect Your Documentation," FPM, November/December 2013.)

The following codes would be reported to describe care of a patient with poorly controlled diabetes, loss of protective sensation, and diabetic ulcer of the left not bad toe with the fat layer exposed:

E11.65, diabetes blazon 2 with hyperglycemia,
E11.forty, diabetes type 2 with neuropathy,
E11.621, diabetic pes ulcer,
L97.502, ulcer left foot, toe, fatty layer exposed.

Annotation that codes for type 2 diabetes are reported even though the documentation did non specify the blazon of diabetes. This is because the guidelines instruct that type 2 is the default when documentation does not specify the type. Also, the ICD-10 alphabetize includes subterms for inadequately controlled and poorly controlled diabetes that direct physicians to report diabetes by type with hyperglycemia.

Number ii: well-kid examinations

Abstruse
First, why should you care?
What to report
Five common diagnoses
Number v: asthma
Number four: otitis media
Number 3: diabetes
Number two: well-kid examinations
And the number one diagnosis is…
Beyond the superlative five
Don't panic
References

The second-most common diagnosis is the well-child visit. Documentation for this encounter requires 2 elements. The showtime is the historic period of the child.

Question: What is the second element you would need to certificate for a well-child visit for ICD-ten?

Whether the test resulted in aberrant findings.
Whether the patient is new.
Established conditions from the problem listing.
Suspected conditions.
Symptoms related to an established diagnosis.

Answer: Aside from the age of the kid, the other chemical element you would need to document for ICD-10 is whether the exam resulted in aberrant findings – answer A. New in ICD-10 are separate codes for routine child health examinations with abnormal findings (Z00.121) or without abnormal findings (Z00.129). Even if an aberrant finding does not merit a separately identifiable evaluation and direction service, if it requires time to come surveillance information technology should be reported as an boosted diagnosis. Report Z00.121 as the commencement code and then add the code for the finding.

Similarly, routine adult health and gynecological examinations are reported based on the presence or absence of aberrant findings; see codes Z00.00-Z00.01 and Z01.411-Z01.419.

As with ICD-9, ICD-10 includes split codes for reporting examinations of newborns less than 8 days old and newborns eight days to 28 days sometime. These codes do not identify the presence or absence of abnormal findings:

Z00.110 Health exam for newborn under 8 days old,
Z00.111 Health examination for newborn 8 to 28 days old.

(See "Table five: Documentation elements for well-kid visits.")

Table five:

Documentation elements for well-kid visits

Age of child	Examination findings	Code
Newborn nether viii days old	northward/a	Z00.110
Newborn 8 to 28 days quondam	northward/a	Z00.111
Child	Abnormal Without aberrant	Z00.121 Z00.129

And the number i diagnosis is…

Abstract
Start, why should you care?
What to report
Five common diagnoses
Number five: asthma
Number four: otitis media
Number 3: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Across the summit five
Don't panic
References

Hypertension is the condition most often reported as the reason for an ambulatory intendance encounter in family medicine.

Question: Which of the following are options for the nomenclature of hypertension in ICD-10?

Beneficial.
Malignant.
Unspecified.
Uncomplicated.
None of the above.

Answer: Under ICD-nine, physicians were challenged to classify hypertension as beneficial, malignant, or unspecified. This is simplified in ICD-10 with a single code, I10, for reporting hypertension, whether described as benign, malignant, or simply essential hypertension. The respond to the to a higher place question, so, is E, none of the above. All the same, coding for hypertensive conditions such as hypertensive center or kidney disease can be more specific. Central documentation guidelines for these atmospheric condition include the following:

Categories I11, I12, and I13 include combination codes that describe hypertensive heart disease with or without middle failure, hypertensive chronic kidney disease, and hypertensive heart and chronic kidney disease. (See "Table six: Documentation elements for hypertensive diseases.")
The causal relationship between hypertension and heart disease must be documented (e.g., due to hypertension or hypertensive). If documentation does non betoken hypertension every bit a cause of the heart disease, separate codes for hypertension and the specified heart condition must exist reported.
An additional code from category I50 must be assigned to identify the type of heart failure in patients with hypertensive eye disease with heart failure.
Unlike hypertension with heart disease, a cause-and-effect human relationship is presumed for hypertension with chronic kidney disease. Report hypertensive chronic kidney affliction when both diseases are present.
Codes in category N18 are reported in addition to the code for hypertensive chronic kidney disease to indicate the stage of the disease.

Table 6:

Documentation elements for hypertensive diseases

Hypertensive disease type	Code family	Complexity
Essential hypertension	I10	north/a
Hypertensive center affliction*	I11.-	With or without eye failure**
Hypertensive chronic kidney affliction	I12.-	With stage v chronic kidney affliction or end stage renal disease With stage 1 through stage four chronic kidney disease, or unspecified chronic kidney disease
Hypertensive heart and chronic kidney illness*	I13.--	With or without middle failure** With stage 5 chronic kidney disease or end stage renal disease With stage 1 through stage four chronic kidney affliction, or unspecified chronic kidney disease

To further illustrate these documentation elements, consider a patient for whom yous have fabricated the following cess: hypertension and left ventricular hypertrophy. Codes assigned for this encounter would exist I10 for hypertension and I51.seven for cardiomegaly. Nevertheless, if your cess was hypertension and hypertensive left ventricular hypertrophy, lawmaking I11.9 would be assigned for hypertensive heart disease without heart failure.

(For more than information on documenting hypertension in ICD-10, see "How to Document and Lawmaking for Hypertensive Diseases in ICD-10," FPM, March/April 2014.)

Beyond the top 5

Abstract
Offset, why should y'all care?
What to study
Five mutual diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number 2: well-kid examinations
And the number 1 diagnosis is…
Beyond the acme five
Don't panic
References

Several common documentation elements back up better coding for weather beyond only the top five diagnoses. These elements – type, location, occurrence, characteristics, and related conditions – are listed with examples of each in "Tabular array seven: Mutual documentation elements." As you review the table, consider how each chemical element might exist applied to diagnoses that you frequently manage.

Table seven:

Mutual documentation elements

Type	Secondary, drug-induced Allergic contact, irritant contact Hyperactive, inattentive, combined Congenital, acquired Clinical classification Nicotine dependence – cigarettes, chewing tobacco, or other
Location	Muscle, tendon, ligament, or joint Sinus cavity Diverticulosis – large or modest intestine Colitis - Area of colon – pancolitis Localized or generalized (eastward.g., edema)
Occurrence	Acute Chronic Acute recurrent Acute on chronic
Characteristics	With or without infarction Refractory, intractable, or not intractable With or without aura With exacerbation Tension-blazon In remission, with withdrawal, or uncomplicated
Related weather condition	Indisposition due to medical condition Flu with respiratory symptoms Late effect (sequelae) of disease Identified infectious agent

Don't panic

Abstruse
Commencement, why should you care?
What to report
Five common diagnoses
Number five: asthma
Number 4: otitis media
Number three: diabetes
Number 2: well-child examinations
And the number 1 diagnosis is…
Beyond the summit five
Don't panic
References

Information technology may have a while to proceeds proficiency and assemble resources to help you certificate and select ICD-x codes that appropriately report the conditions you are managing. Acknowledging this, the Centers for Medicare & Medicaid Services and the American Medical Clan recently appear a one-year grace catamenia during which Medicare claims will non exist denied solely because the diagnosis lawmaking is not specific enough – every bit long as it is from the appropriate family of ICD-x codes (the three-character category) and is a valid code.

As you become more familiar with the codes, work toward greater specificity and accurateness, and wait for ways to improve your coding and documentation processes and systems. For case, y'all might ask your electronic health record vendor about creating a "favorites" list of ICD-10 codes. Just remember that this time of transition will laissez passer, but adopting better documentation and coding habits that capture the true nature of the conditions you lot manage and the quality of care you provide will be to your advantage as heath care transitions from fee-for-service to value-based payment.

Manufactures IN FPM'S ICD-10 SERIES

You tin access the following articles in FPM's ICD-10 topic drove:

"ICD-10: Major Differences for Five Common Diagnoses," FPM, September/October 2015.

"ICD-10 Sprains, Strains, and Automobile Accidents," FPM, May/June 2015.

"Digesting the ICD-10 GI Codes," FPM, Jan/Feb 2015.

"Coding Common Respiratory Problems in ICD-x," FPM, November/Dec 2014.

"ICD-x Simplifies Preventive Care Coding, Sort Of," FPM, July/Baronial 2014.

"ICD-10 Coding for the Undiagnosed Problem," FPM, May/June 2014.

"How to Document and Code for Hypertensive Diseases in ICD-ten," FPM, March/Apr 2014.

"x Steps to Preparing Your Office for ICD-10 – At present," FPM, January/Feb 2014.

"Getting Ready for ICD-ten: How It Will Touch Your Documentation," FPM, November/December 2013.

"The Anatomy of an ICD-10 Code," FPM, July/August 2012.

"ICD-10: What You Need to Know Now," FPM, March/April 2012.

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About the Author

Cindy Hughes is an independent coding consultant based in El Dorado, Kan., and a contributing editor to Family unit Exercise Direction.

Author disclosure: no relevant fiscal affiliations disclosed.

References

1. National Convalescent Medical Care Survey, 2009. Hyattsville, Dr.: National Center for Health Statistics; 2011.

2. National Asthma Education and Prevention Program. Expert Console Report 3: Guidelines for the Diagnosis and Direction of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007.

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